Primary Care Network Direct Enhanced Services (PCN DES)
Direct Enhanced Services are nationally commissioned programmes delivered through Primary Care Networks to improve access, quality, and outcomes in general practice. In City and Hackney, these services support practices to work together, share specialist roles, and provide more proactive and personalised care for local people. City and Hackney Integrated Primary Care supports PCNs to plan, coordinate, and monitor delivery, ensuring services are consistent, evidence based, and focused on reducing health inequalities across our communities.
Structured Medication Reviews
Our network carries out regular structured medication reviews to help patients get the best results from their medicines. These reviews identify potential side effects, reduce unnecessary prescriptions, and support people in managing their conditions safely. By monitoring completion rates and follow-up actions, we ensure our prescribing remains safe, evidence-based, and centred on patient wellbeing.
Early Cancer Diagnosis / Screening Uptake
Detecting cancer early gives patients the best chance of recovery. Across our PCNs, we actively monitor and improve participation in cancer screening programmes, such as cervical, bowel, and breast screening. We work with local partners and community organisations to raise awareness, reach under-screened groups, and ensure timely referral for diagnostic tests.
Access and Continuity of Care
Workforce and Additional Roles (ARRS)
Our PCNs employ a wide range of professionals through the national ARRS programme. These include pharmacists who review medicines, first-contact physiotherapists for musculoskeletal issues, and link workers who connect patients with community support. We track the number, skill mix, and impact of these roles across our practices to ensure every patient can benefit from the right expertise at the right time
Learning Disability Annual Health Checks
We offer annual health checks for people aged 14+ on the Learning Disability register. Checks include a personalised Health Action Plan and recording of ethnicity, so care is safer and better tailored. We track completion across all practices and focus outreach on anyone who’s missed a check to reduce gaps in care.
Social Prescribing
Our social prescribing link workers help people with non-medical needs — such as isolation, housing, money worries or long-term condition self-management — by connecting them to community support. We record referrals using national SNOMED codes, track outcomes from brief interventions through to sustained engagement, and work with local VCSE partners to keep the offer inclusive and easy to access.
Proactive Care
We use risk-stratification to identify people at greatest risk of deterioration or admission and offer coordinated, multidisciplinary support in neighbourhood teams. Plans typically cover medicines safety, frailty, long-term condition control and escalation advice. We monitor uptake, unplanned admissions, and patient-reported confidence to make sure the approach is working.